MEDICARE: MRS. KRISTEN L LONG LPC, CACII

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LPC-16476	AZ

General Provider Information

NPI Number	:	1275808883
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KRISTEN L LONG LPC, CACII

Provider Business Mailing Address
First Line	:	84 ACOMA BLVD N STE 104
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6096
Country	:	US
Telephone Number	:	928-733-5101
Fax Number	:	970-249-2955

Provider Business Practice Location Address
First Line	:	84 ACOMA BLVD N STE 104
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6096
Country	:	US
Telephone Number	:	928-733-5101
Fax Number	:	970-249-2955

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2012
Last Update Date	:	12/12/2022

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